Primary care toolkit Contents Section 1

What is the primary prevention programme? What is the Lifestyle Support Programme? Who are the lifestyle coaches?

Section 2

Contact details for the lifestyle support team

Section 3

Oberoi software tool Step by step guide to using Oberoi



Section 4

Section 5



Inviting patients to attend the programme Protocol for inviting patients Cardiovascular screening flowchart Invitation letter Reminder letter Patient information leaflets to be included with letters Why should I attend this health check? What to expect at your health check appointment How to arrange fasting blood test. Protocols Primary prevention protocol Template user guide

Section 6

Referral to lifestyle coach Guidance for practice staff Inclusion criteria Referral form Patient information leaflets to be given on completion of health check Clinical results Your consultation with the lifestyle coach Copy of signed referral letter Who should be treated to reduce CVD risk? Cholesterol information leaflet if required

Section 7

NICE guidelines Lipid management Diabetes management Obesity care pathway

Section 8

Local enhanced service agreements

Section 9

Case scenarios

Section 10

Randomised control trial

Section 11

Additional informtion

What is the primary prevention programme? NHS Stoke on Trent has introduced a cardiovascular risk reduction programme that is being rolled out across the City during 2008/11. Stoke on Trent has a significantly high incidence of cardiovascular disease (CVD), diabetes and obesity, all of which are influenced by associated lifestyle factors. This toolkit has been developed to help you identify, support and meet the needs of patients who are at an increased risk of CVD, developing or have already been diagnosed with CVD or diabetes and those who have completed a cardiac rehabilitation programme. The Lifestyle Support Programme offers timely interventions to aid reduction in developing and/or the progression of these diseases. Key elements of the Lifestyle Support Programme include: • CVD risk assessment • Primary prevention management and support • An opportunity for patients to attend regular reviews that will help to manage their CVD risk in the long term • Signposting ‘well motivated‘ patients to the lifestyle programme for up to 12 months ongoing support • Provide personalised support for patients via a team of lifestyle coaches Primary prevention of cardiovascular disease Oberoi software has been installed in each practice which provides practices with the opportunity to identify patients at high risk of developing CVD. Having identified those at risk, members of the primary prevention team (or general practice team) will invite patients to attend an appointment to validate the Oberoi findings. This appointment will be used to develop a patient’s care plan which includes updating the primary prevention template, estimating the CVD risk, appropriate prescribing in line with the CVD risk, planned review appointments, and referral into the Lifestyle Support Programme if the patient is motivated to make sustainable lifestyle changes.

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What is the Lifestyle Support Programme? The Lifestyle Support Programme (LSP) offers those who meet the inclusion criteria the opportunity to receive at least 6 months of personalized lifestyle support. The LSP will offer a one to one consultation with a lifestyle coach, the opportunity to discuss, develop and negotiate a personalised health improvement plan based on lifestyle improvement priorities identified by the patient. An assigned lifestyle coach will offer a maximum of six hours support per person over a six month period with set review meetings during this time, and a final review at 12 months. • Each person will be able to develop their own personal health improvement plan based on their identified goals. They will have the opportunity to access a selection of activities designed to help them in their lifestyle changes. These are: • Physical activity sessions (free 20 week programme) • Weight management support (free Weight Watchers vouchers) • Cook ‘n’ eat educational and practical sessions • Access to smoking cessation support.

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Who are the lifestyle coaches? Part of the ‘Choosing Health’ recommendations (DH 2004) to Primary Care Trusts was the development of a National Health Trainer role to work in local communities. NHS Stoke on Trent developed the Lifestyle Support Programme and the lifestyle coach role from the national picture, tailoring it to meet the needs of local communities. The lifestyle coaches are a qualified team of people recruited from local communities to provide support for people making lifestyle changes. As well as specific training for the role, the lifestyle coaches also bring their varied knowledge, skills and life experience to the Lifestyle Support Programme. Following referral from primary prevention risk screening to the Lifestyle Support Programme (LSP), each client will be assigned a personal lifestyle coach. The lifestyle coaches are able to provide accurate and clear information to patients (and colleagues), and support each patient through a process of lifestyle change(s). Initially there will be a 45 - 60 minute meeting to identify the lifestyle changes that the person/ patient would like to make. At this meeting a personal health plan will be developed and, if it is appropriate at this point, the lifestyle coach may signpost a patient to an additional activity that is suitable for their need(s). Subsequent contact may be face to face, by telephone or text messaging, whichever is the client’s preferred method. ‘Milestone reviews’ at 3 and 6 months will be face to face meetings. Flexibility is a key feature of the lifestyle support team ensuring patients can see a lifestyle coach at a time and venue to suit them. Information and data will be accurately recorded for monitoring and evaluation purposes and feedback will be given to all referring practices. The lifestyle support team is based at Bentilee Neighbourhood Centre, and works across the NHS Stoke on Trent area in accessible locations.

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Contact details for the Lifestyle Support Programme Professional leads for primary prevention Yvonne Mawby   [email protected] Linda Picariello    [email protected] Heron House 120 Grove Rd Fenton ST4 4LX Tel 01782 298175 Project support workers Karen Hales [email protected] Tracy Pepper   [email protected] Joanne Fynn [email protected] Heron House Tel 01782 298175 Please contact us if you have any queries regarding the primary prevention programme in your practice.

Lifestyle Support Service Manager Marion Beloe   [email protected] Bentilee Neighbourhood Centre Dawlish Drive Bentilee Stoke on Trent ST2 OEU Tel. 01782 231372 Fax: 01782 231881 Mobile: 07515 190463 Safe haven fax number for receiving referral letters

01782 298054

Marion will be able to facilitate contact with the city wide lifestyle coach team.

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Professional manager Lifestyle Support Programme Chris Leese [email protected] Heron House Tel: 01782 298177 Deputy Director of Public Health Dr Zafar Iqbal [email protected] Heron House Tel 01782 298146 Clinical champion Dr Ruth Chambers

[email protected]

IT project support worker Danish Jafri [email protected] Herbert Minton Building Tel 01782 298213 Administrator –Lifestyle Support Programme Donna Bailey [email protected] Heron House Tel. 01782 298053

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Oberoi Training Step by step guide

Oberoi software has been installed in all practices that are participating in the Lifestyle Support Programme. Its prime function is to identify patients most at risk of CVD. Oberoi uses data extracted from the practice’s clinical system and ‘estimates’ values that have not been recorded in the medical record to enable the user to invite patients in for screening To access the software, double click on to the Oberoi icon on the computer desktop. Username: oco Password: prevention In order for Oberoi to work effectively, queries have been developed to run in conjunction with the practice’s clinical system. The queries should be run fortnightly to ensure that the data held is up-to-date, accurate and relevant. You can check when the data was last run by looking at the pale blue bar above the patient details – the date it was last run will appear on the right hand side (i.e. analysed on Monday 18th Feb 2008). To run the queries, click onto the yellow cog – when you hover over this icon it states ‘analyse clinical data’. A blank data analysis window will open – click onto the analyse button. Queries can take anything from 5 minutes to 1 hour 30 minutes to run. Important Note – If Oberoi is installed on more than one computer the responses will only appear on the machine used to run the queries. You can continue to use the clinical system whilst the queries are being run. Oberoi will indicate when the queries are complete. Click onto the ‘close’ button to take you back to the software. You can now browse updated patient details. You will see that the date that the analysis took place is viewable in the pale blue bar (as previously stated).

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Definitions within Oberoi ID – Is the number the clinical system has given to identify the patient Diagnosed? – Y/N identifies whether the patient already has CHD Hypertensive? – Y/N identifies whether the patient already has hypertension Estimated? – Has the patient’s CVD/CHD risk been estimated? If these items of information are missing Oberoi will estimate a value. On Register – Only patients who have had a Framingham risk recorded in their records will have data recorded in this column. It will not state the %, just whether it has been done and the date it was entered. Patients who should be invited for primary prevention screening in the first instance will be those with ≥ 25% risk. The column you need to select to pick up this value is CHD x 4/3. To sort the risk in descending order click once on the grey column CHD x 4/3. Points to Note All of the risks are colour coded within 3 thresholds ≥ 20.1% will be shown in red. Between 10.1% and 20% for CVD over 10 years n • On Diabetes Register or have Impaired Glucose Intolerance n • Identified Cardiovascular Disease n • Having undergone Cardiac Rehabilitation to at least Phase III and been fully discharged to Primary Care n It is also important to establish that the client’s condition is well controlled and there are no existing complications that may preclude the client from participating in a moderate intensity physical activity programme.

Comments – please list any medical conditions that may limit physical activity.

Systolic BP Diastolic BP Pulse Rate CVD Risk Score B.M.I. Waist Circumference Well motivated Yes n No n

List medications: Heart

n

Hypertension

n

CVD Prevention

n

Diabetes

n Insulin

Asthma / COPD

n

Pain Management n

GTN n e.g. aspirin, statin

n

Tablets n

Inhaler(s) n

Tablets n

Analgesics / NSAIDs

n

You may wish to print off the patient’s ‘current’ prescription drug list and fax with the form.

I agree that I am well motivated and understand that my personal details will be used for evaluation purposes by Staffordshire University. I also understand that my personal and medication details will be stored securely and may be shared with members of the Lifestyle support delivery team (Voluntary Action Stoke on Trent and Stoke on Trent City Council) in order that I receive the best possible advice. I will inform the lifestyle coach of any changes in my condition or medication. Signature of patient __________________________Date____/____/____ Print Name­­­________________________ I agree that the patient meets the inclusion criteria as set out in the Lifestyle Support Programme toolkit. The patient’s current health is well controlled and I know of no other existing reasons why the patient is not fit for everyday physical activity, which may preclude the patient from participating in this programme. Signature of referrer _________________________Date____/____/____ Print Name­­­________________________ To be completed by Programme Admin Team

Practice information & contact number

Programme commenced / completed

_______________________________

Commenced Lifestyle Programme

____/_____/______

_______________________________

Date completed Lifestyle Programme ____/_____/______

_______________________________

Date completed information sent back to original referrer ____/_____/______

_______________________________

Fax to Lifestyle Support Programme Administrator on 01782 298054 and please give a copy to client

Patient Information

Patient Information leaflet

Clinical results and actions Name:

Date:

Ideal Score My Weight is: My waist circumference is:

Your Agreed Action Score

Men: less than 102cm (40.5”) Women: less than 88cm (34.5”)

My body mass index (BMI) is:

Normal:20-25kg/m²

My smoking habit is:

No tobacco

My alcohol intake is:

Men: ≤ 21 units per week Women: ≤ 14 units per week

My total cholesterol level is:

≤ 5 mmol/l

My glucose level is: fasting/non fasting

Fasting: less than 7mmol/l Non Fasting: less than 11.1mmol/l

My blood pressure is:

Below 140/90mmHg and lower if you have diabetes

My cardiovascular risk is:

Less than a 20% risk in the next 10 years

My level of physical Ideal score = at activity is: least 5x30 minutes moderate intensity sessions per week Agreed changes that I may need to make to my diet My next appointment with the surgery is due:

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Follow up Appointment

Patient Information leaflet

Your consultation with a lifestyle coach The Lifestyle Support Team is a team of local people from across Stoke on Trent who are qualified to support you through your chosen lifestyle change(s). You will be assigned a personal lifestyle coach and will remain in contact with that same coach until you complete your programme. Your lifestyle coach will work with you to identify what improvements you would like to make to your lifestyle and support you in developing a personal health plan to achieve your chosen lifestyle change(s). The first meeting will take 45 – 60 minutes to allow enough time for you to discuss the areas you would like to improve and identify any barriers to lifestyle change(s). At the end of the initial meeting, you and your lifestyle coach will agree the level of support you require and also when you would like to make contact again to discuss your progress. Follow up contact may be face to face, a telephone call or even a text message, whichever method is most convenient for you. Your lifestyle coach will be as flexible as possible, within boundaries, to meet your requirements. As well as contact with your lifestyle coach you will be able to choose from a number of local activities, free of charge, that will help you in achieving your lifestyle change(s). The activities on offer include: Weight management sessions – Your lifestyle coach can provide you with 12 weeks of free vouchers to a local Weight Watchers group. Physical Activity Sessions – A free 20 week physical activity programme offering you the opportunity to take part in activities at local venues. These include:

• Walking groups • Exercise to music • Gym visits • Relaxation classes e.g. Tai-chi, yoga and Pilates • Swimming

You may be entitled to an ‘Energiser Plus’ card at week 10 of your programme, which will allow you up to 50% discount on many physical activity opportunities across the city. Cook & Eat

3 practical sessions to increase your knowledge, skills and confidence in making, preparing and cooking healthy food choices.

Think Positive 3 two hour workshops that explore health and well being in relation to your lifestyle.

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Patient Information leaflet

Who should be treated to reduce their cardiovascular health risk? In general, treatment to reduce the risk of developing a cardiovascular disease is usually offered to people with a high risk. That is: • People with a cardiovascular risk assessment score of 20% or more. This means, if you have a 2 in 10 chance or more of developing a cardiovascular disease within the next 10 years. • People with an existing cardiovascular disease (to lower the chance of it getting worse or of developing a further disease). • People with diabetes. If you have diabetes, the time that treatment is started to reduce cardiovascular risk depends on factors such as: your age, how long you have had diabetes, your blood pressure, and if you have any complications of diabetes. • People with certain kidney disorders. What treatments are available to reduce the risk? If you are at high risk of developing a cardiovascular disease then drug treatment is usually advised along with advice to tackle any lifestyle issues. This usually means: • Drug treatment to lower your cholesterol level, usually with a statin drug. No matter what your current cholesterol level, drug treatment is advised. • Drug treatment to lower blood pressure if your blood pressure is high. This is even if your blood pressure is just mildly high. • A daily low dose of aspirin - depending on your age and other factors. Aspirin helps to prevent blood clots from forming on patches of atheroma. • Encouragement to tackle lifestyle risk factors. This includes: • Stop smoking if you smoke. • Eat a healthy diet. • Keep your weight and waist in check. • Take regular physical activity. • Cut back if you drink a lot of alcohol. You may be offered a referral to a specialist service if you have a cardiovascular risk ≥ 20% in the next ten years; for example, to the lifestyle programme to help you to lose weight and eat a healthy diet, or to a specialist ‘stop smoking clinic’. What if I am at moderate or low risk? If you are not in the high risk category, it does not mean you have no risk - just a lesser risk. You may be able to reduce whatever risk you do have even further by any relevant changes in your lifestyle (as described above).

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Patient Information leaflet

Understanding cholesterol You will usually be advised to take a statin drug to lower your cholesterol level if you have a high risk of developing a cardiovascular disease such as heart disease or stroke, or developing diabetes. As a rule, no matter what your cholesterol level is, then lowering the level reduces your risk of these health problems. UK guidelines recommend that all people aged 40 years old or older should have a cholesterol blood test as part of a routine cardiovascular risk assessment. What is cholesterol? Cholesterol is a lipid (fat chemical) that is made in the liver from fatty foods that we eat. A certain amount of cholesterol is present in the bloodstream. You need some cholesterol to keep healthy. Cholesterol is carried in the blood as part of particles called lipoproteins. There are different types of lipoproteins, but the most relevant to cholesterol are: • low density lipoproteins carrying cholesterol - LDL cholesterol. This is often referred to as ‘bad’ cholesterol as it is the one mainly involved in forming atheroma. Atheroma is the main underlying cause of various cardiovascular diseases (see below). Usually, about 70% of cholesterol in the blood is LDL cholesterol, but the percentage can vary from person to person. • high density lipoproteins - HDL cholesterol. This is often referred to as ‘good’ cholesterol as it may actually prevent atheroma formation. What are atheroma and cardiovascular diseases? Patches of atheroma are like small fatty lumps that develop within the inside lining of arteries (blood vessels). Atheroma is also known as ‘atherosclerosis’ and ‘hardening of the arteries’. Patches of atheroma are often called ‘plaques’ of atheroma. Over months or years, patches of atheroma can become larger and thicker. So, in time, a patch of atheroma can make an artery narrower, which can reduce the blood flow through the artery. For example, narrowing of the coronary (heart) arteries with atheroma is the cause of angina. Sometimes a blood clot (thrombosis) forms over a patch of atheroma, and completely blocks the blood flow. Depending on the artery affected, this can cause a heart attack, a stroke, or other serious problems. Cardiovascular diseases are diseases of the heart (cardiac muscle) or blood vessels. However, we generally use the term ‘cardiovascular disease’ to mean diseases of the heart or blood vessels that are caused by atheroma.

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NICE guidelines

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Lipid management

Section 7 : Page 2

Diabetes management

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Obesity care pathway

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Primary Prevention Programme LES: Option B Use of PCT staff to implement primary prevention Introduction All practices are expected to provide essential, and those additional services they are contracted to provide, to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services. The LES is established to recognise additional work other than the normal care of patients in carrying out the primary prevention programme for patients who have a > 25% cardiovascular (CVD) risk in subsequent ten years where they use the PCT Primary Prevention clinical support team instead of a practice staff to undertake primary prevention. The LES is aiming to provide a service initially for those at a risk greater than 25% as the numbers of patients at > 20% CVD risk are too large. This does not alter the recommendations from guidelines that those at a risk > 20% should be offered treatment but the initial priority will be those at CVD risk ≥ 25%. The LES is designed to reimburse costs to a general practice that initiates primary prevention in line with the PCT’s primary prevention programme protocol through the PCT Primary Prevention Clinical Support team providing call, recall and audit services. The LES is designed to help practices to deal with initiation of primary prevention for the backlog of patients identified through the Oberoi software tool. The LES does not cover the on going identification of new cardiovascular high risk patients and the follow up treatment of these patients. This LES will be reviewed for 2009/10 and 2010/11 and 2011/12. It applies to all 55 general medical practices in Stoke-on-Trent PCT with 147 GPs within the five practice based commissioning (PBC) clusters. Practices will have to decide whether to opt for either option A use of practice staff to initiate primary prevention or option B for use of PCT Primary Prevention Programme Clinical Team.

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Background The life expectancy gap between England and Stoke is so great that high impact programmes are required at a population level where measures are taken to encourage the whole population to improve lifestyles, and at an individual targeted level focusing on people with high risk of developing long-term conditions. The Local Strategic Partnership (LSP) is developing city wide approaches to improve lifestyles. The ward rankings from the Index of Multiple Deprivation 2004 show that the majority of wards in Stoke on Trent (18 out of 20) fall into the top 20% most deprived wards nationally. The total population of Stoke-on-Trent is 276,414; of these 132,078 are in the 35-74 year old age group. It is expected that in the region of 16900 people in this age group might be identified by the intended software to be at potentially high risk of CVD; and that nearly two-thirds of these might attend an initial risk assessment arranged by the clinical project assistant acting for the practice. Estimates of numbers of people per practice population with a body mass index > 25, and of those on diabetes and CHD registers have been assessed to calculate potential workload for the primary prevention programme and lifestyle support programme. The proposed programme is in keeping with the national direction on screening for common diseases announced by the Prime Minister (7 January 2008) and expected focus on cardiovascular screening. Both the CHD NSF and NICE guidelines recommend the identification and management of adults considered to be at risk of CVD. Statin and aspirin therapy is recommended as part of the management strategy for adults who have a ≥ 20% ten year risk of developing CVD by the Joint British Society Guidelines; statins are recommended by NICE for adults who have > 20% risk of developing CVD (or >15% of developing CHD) over ten years.

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Benefits expected are: 1. Improved life expectancy: It is estimated that if 10,000 people take up the CVD primary prevention programme this will lead to around 100 fewer cardiovascular events per year (e.g. death, myocardial infarction). 2. Cost- effective management of those at high risk of developing CVD. 3. Easily accessed lifestyle support for local people that aids the general practice management of patients in terms of primary prevention of CVD and secondary prevention of CHD and diabetes. Aims of Primary Prevention Programme 1. Identify people registered as patients with general practices in Stoke-on-Trent PCT who are at high risk of cardiovascular disease (CVD) and offer them appropriate medical management and lifestyle support. 2. Refer appropriate patients with significant CVD risk to a lifestyle support programme to underpin the primary prevention programme; and extend primary prevention programme to refer those patients known to have coronary heart disease (CHD) or diabetes or who have recently had cardiac rehabilitation too. 3. Raise awareness of those working with and for general practices in Stoke-on-Trent, their patients and the population at large about the campaign to promote primary prevention of cardiovascular disease; and the existence and potential benefits of the associated lifestyle support programme. Service Agreement The PCT The PCT will employ at least three Clinical Project Support Workers at band 4 who are expected to start working for the project on 1.7.08. If the project progresses well and the majority of practices prefer to host the PCT clinical support workers rather than utilise their own practice staff, then it is intended to employ two more project support workers in September 2008. The PCT will provide • IT software to identify patients suitable to be screened by the practice team that can be loaded into the practice computer system. Then provide training for the practice team in loading and utilising the project software tool and set up a primary prevention register of patients (ie untreated patients) with a CVD risk> 25% in next ten years. • help to establish the practice primary prevention register by seeking personal information about patients who may be at risk, but where the practice does not have sufficient personal information to be able to attribute an individual risk score.

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• • • • • • • • • • •

a clinical project manager (YM or LP) to train and support the practice team in setting up the PCT primary prevention programme protocol – at cluster events or practice-based. a clinical support worker expected to be based in the practice to undertake call and review patients with a CVD risk ≥ 25% to the primary prevention programme in line with the PCT project protocol. referral to the practice clinical team for treatment of hypertension or raised cholesterol or smoking habit as appropriate. referral to the Lifestyle Support Programme if appropriate a Primary Prevention Programme / Lifestyle Support Programme toolkit. stationary and postage involved in call/recall of patients with CVD risk ≥ 25%. reasonable training and development as identified during the project process, as applicable to the PCT’s primary prevention protocol mentorship and support for the practice team in relation to the initiative a clear communication channel for the practice team should a problem arise phlebotomy service to which patients are directed to have their blood taken for screening prior to their initial health check up in the practice (if there is a need for additional phlebotomy the PCT will make the necessary arrangements). postage costs

The practice All participating practices will provide: • care in line with PCT primary prevention guidelines • suitable accommodation and equipment to carry out screening of patients e.g. BHS approved blood pressure machine, weighing scales and access to computer for clinical / administrative duties. This might include opening in the evenings / weekends to accommodate the project and patient needs. Consumables relevant to the roles of the project support worker e.g. urinalysis sticks • access to patient information and to input data on to the practice system by the designated PCT clinical support worker. • appropriate administrative support e.g. to provide access to clinical systems and access to telephone to contact patients • normal routine care for patients with CHD/diabetes/hypertension in the spirit of the Quality and Outcomes Framework

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• • • • •

a doctor to review screening information, blood tests and associated risk scores and action follow-ups as necessary once an assessment and review has been undertaken by the PCT clinical support worker. The practice clinical team must respond to abnormal clinical findings in line with best practice in ongoing medical management of raised cholesterol, raised blood pressure, smoking habit, overweight or obesity. Specifically in the case of a raised blood pressure detected at the initial assessment by the PCT employed clinical project support worker, follow up with two more blood pressure measurements on separate occasions to establish if there really is a case of hypertension. initiate appropriate medication as per Stoke on Trent PCT formulary should patients be identified as requiring treatment. Follow up and titration of medication if prescribed. a review of patients at one year. support for referral to the Lifestyle Support Programme organised by the PCT clinical project support worker, encouraging individual patients who would benefit to attend or continue on the LSP programme; referring those to the LSP who were initially reluctant to agree but have changed their minds. Make available to the PCT data for evaluation

Clinical Governance The clinical accountability for the PCT primary prevention support team will rest with PCT clinical managers. Service monitoring An annual audit will be undertaken as part of the enhanced service contract review by member of PCT staff. Accreditation Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so Termination of Agreement Either party will be entitled to terminate this agreement by three month’s notice if one of the others is in material, serious, or repeated breach of its obligations under this element. Notice should be served in writing on the defaulting partner, specifying the failure to fulfil its obligations and the remedial action that should be undertaken, within a specified time period

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If any partner terminates the agreement before the agreement has expired, the agreement value shall be a pro rata proportion of the fee, and any financial adjustment shall be paid. For practices that close down, split, merge or start up in-year, it will be for the PCT to decide with that practice what awards will be made to them in respect of this LES. If other agreements such as the QOF incorporate primary prevention then the PCT will review the LES to ensure it is not paying twice for such a service. Costs Each provider contracted to provide this service will receive a one-off payment of 25p per registered patient for setting up the system for delivering the service as a one off payment when the practice actively starts on the primary prevention programme. Payment will be due when the practice has been actively calling up and reviewing identified patients with a cardiovascular risk ≥ 25% to the initial health check according to the PCT project protocol – for a three month period.

Signature page for Local Enhanced Service Primary Prevention Programme Option B Use of PCT staff to implement primary prevention 2008/9

For or on behalf of the Commissioner



For or on behalf of the practice (Please stamp):

Stoke on Trent PCT Herbert Minton London Road Stoke-On-Trent ST4 7PZ

Signed ……………………………



Signed: ………………………

Date ………………………………



Date: …………………………

Name ………………………………

Name: ………………………..

Designation ……………………...

Designation……………………

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The following two case scenarios offer examples of how the Lifestyle Support Programme could support your practice population.

Case scenarios 1. Bob- Identifying people at risk of developing diabetes (We know from the United Kingdom Prospective Diabetes Study (UKPDS1990) that approximately half the people with newly diagnosed diabetes were already showing complications from their condition, which suggested that the condition had been present but undiagnosed for 5-10 years. The progress from normal glycaemia to diabetes (type 2) is gradual, so it is important that health care professionals try to identify possible ‘at risk’ people and diagnose the pre-diabetes state (fasting blood glucose 6.1-6.9 mmol/L) and offer advice and support to reduce the chances of the person developing diabetes.) Bob, aged 53 years old, has attended for his primary prevention health check. He is currently being treated for hypertension; his blood pressure is well controlled at 131/82 mmHg. He has attended for routine blood testing prior to his appointment. At the initial health check, his history and blood results appear to indicate that he has a collection of risk factors, which indicate the metabolic syndrome, which includes impaired fasting glucose, dyslipidaemia, central obesity as well as his previously diagnosed hypertension. All these risk factors culminate in an increased CVD risk in the next 10 years. In order to assess Bob’s glycaemic state, you order a repeat fasting glucose and this is reported as being 6.2 mmol/L. (Diabetes is confirmed when two fasting blood glucose levels are ≥7 mmol/L, so this result does not fall into this category. However, the result is not normal as it is over 6.1mmol/L. These results show that Bob may have an abnormal glucose metabolism, with all the increased risks associated with this.) How will you manage him? It would be easy to give some dietary advice and diet sheets and send him on his way. There is good evidence to suggest that impaired fasting glucose levels respond to lifestyle changes; so by advising Bob to lose weight, become more active and increase his muscle mass will have an impact on the way his body utilizes glucose. He is motivated to lose some weight as he is in a new relationship and is embarrassed by his ‘beer belly’. It is important that Bob understands that these recommendations will have a life changing impact on his future health. This will include helping him to understand the way in which his body will improve the way it deals with blood sugar levels, leading to healthier glucose metabolism in the future. He needs to understand that building up muscle will help to increase the amount of sugar that is removed from the blood stream, so helping to reduce his high blood sugars. Bob will also benefit from dietary advice, and being made aware of low fat and sugar options.

Section 9 : Page 1

As Bob is motivated to alter his lifestyle a referral to the local lifestyle coach will be arranged, offering personalized support to help achieve his goals. Bob will need to be supported and monitored to assess his future risks, so follow up appointments need to be arranged with the practice nurse to repeat his blood pressure, waist circumference, body mass index, blood tests and to maintain motivation to lead an active lifestyle. Reference: Manley SM, Meyer LC, Neil Haw. UK prospective Diabetes Study 6. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. Diabetes Res. 1990; 13:1-11. 2. Anne - Identifying people with a cardiovascular risk ≥ 25%: then what? Anne is obese and has not had her blood pressure measured for several years and is rather depressed. Anne is identified as having a raised cardiovascular risk, when the PCT project support worker runs the search on the patient population aged 34 – 75 years old for practice X. The project support worker looks at Anne’s medical records and decides that she needs her blood checked (which according to the PCT protocol is for a general screen, fasting glucose, fasting lipids and thyroid function tests) before she is seen for a health check in the practice by the support worker. When she comes to the practice for the health check the blood test results are back, and the project support worker can see that she has fasting total cholesterol of 6.5mmol/L, a fasting glucose of 5.8mmol/L, normal thyroid function and general screen. At the health check, the project support worker notes that Anne’s blood pressure is raised at 168/97mmHg (right arm) and 175/102mmHg (left arm) taken with a large sized cuff- as Anne is obese with a body mass index (BMI) of 34. The project support worker notes that Anne smokes (has done for 20 years since age 15 years old) and that her waist measures 126 cms. Her only exercise is walking to the corner shop down the road as she travels in her car to her work as an office secretary, where she sits more or less all day at her desk. Anne does seem to be motivated to change, judging from her motivation test score. So the project support worker discusses the benefits of the lifestyle support programme with Anne, and refers her to the lifestyle coach, Jed, who can see her the following week at a time that suits Anne. Anne books in to see the practice nurse for her blood pressure to be retaken a fortnight later, and resolves to discuss what help she can get with giving up smoking from the practice nurse- she’s heard of patches and all that on Signal radio. The project support worker has made her feel that there’s hope – she should be able to get help with losing weight, and for her depression- she really does not want to take tablets which is the only treatment she’s been offered before by her GP.

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